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DATA PRIBADI Nama : Dr. dr. Retno Ariza Soeprihatini Soemarwoto, Sp.P (K) FISR
TTL : 24 Maret 1967
Alamat : Jl Way Rarem 12 Pahoman Bandarlampung
RIWAYAT PENDIDIKAN
FK UKI Jakarta
Pumonologi dan Kedokteran Respirasi FK UI Jakarta
Doktoral Biomedik FK Unand Padang
Pekerjaan
Kepala Puskesmas Sukoharjo, Lampung Selatan ( 1995 – 1998 )
Direktur RS Wisma Rini Pringsewu ( 2005 – 2006 )
Wakil Dekan Bidang Kepaniteraan FK Unimal ( 2006 – 2009 )
Komite Medik RS Harapan Bunda, Bandar Jaya Lampung Tengah 2005 – 2012 )
Pulmonologist RS Harapan Bunda, Bandar Jaya Lampung Tengah (2005 – 2011)
Pulmonologist RSU Pringsewu (2011 – 2015 )
Pulmonologist RS A Dadi Tjokrodipo Bandar Lampung (2011 – 2018 )
Pulmonologist RS Abdul Muluk Bandar Lampung (2015 – sekarang )
Koordinator PPDS Pulmonologi dan Kedokteran Respirasi FK UNILA (2018 – sekarang )
How to manage COPD and Asthma exacerbation
Retno Ariza Soeprihatini Soemarwoto, Department of Pulmonology and Respiratory Medicine,
Faculty of Medicine, Universitas Lampung, Abdul Muluk General Hospital Bandar Lampung, Indonesia.
Pendahuluan
Asma di dunia → 300 juta orang dengan 250.000 kematian /tahun
PPOK → penyebab kematian no.4 di dunia pada 2013 (diperkirakan ke 3 pada 2020)
PPOK di Asia → 6,3% (prevalensi tertinggi di Vietnam dan RRC)
2,4 % ASMA
57, 5% mengalami kekambuhan dalam 12 bulan
PPOK dan Asma di AS
• 14,2 juta, lebih dari 1,5 juta kunjungan ke IGD/tahun dengan angka kematian no 4 di dunia • Eksaserbasi PPOK → $49,9 milyar/tahun. • Perawatan RS meningkat 20% - 30% dari tahun 2002 – 2012
• Dewasa: 1 dari 12 orang • Anak-anak: 1 dari 10 orang • > 2 juta kunjungan ke IGD dengan angka kematian 4000 orang • eksaserbasi asma → $56 milyar/tahun
Definisi Ekserbasi Asma
Asma adalah penyakitheterogen, biasanya ditandai oleh inflamasi saluran napas kronik.
Eksaserbasi asma adalah keadaan akut dimana terjadi perburukan gejala dan fungsi paru dari kondisi pasien asma sehari hari.
ASTHMA OVERVIEW DEFINITION, CHARACTERISTIC, SYMPTOMS
ASTHMA is a CHRONIC AIRWAY INFLAMMATION
SYMPTOMS : • WHEEZE
• SHORTNESS OF BREATH • CHEST TIGHTNESS
• COUGH
There is an airflow limitation and varies over time and intensity. Triggered by exercise, allergen exposure, changes in weather, viral infection
DIAGNOSIS BY SPIROMETRY
AIR FLOW OBSTRUCTIONS
BRONCHIO HYPERRESPONSIVE
INFLAMMATION
; Global Strategy for Asthma Management and Prevention (2016 Update)
Symptoms are worse during early in the morning and night
Definisi Ekserbasi PPOK
PPOK adalah penyakit yang umum, dapat dicegah dan dapat diobati, yang dicirikan dengan gejala pernafasan yang menetap dan keterbatasan aliran nafas yang disebabkan oleh abnormalitas saluran nafas atau alveolar yang biasanya disebabkan oleh paparan signifikan partikel atau gas beracun
Eksasebasi PPOK didefinisikan sebagai perburukan akut gejala saluran nafas yang membutuhkan terapi tambahan
Faktor Risiko Eksaserbasi Asma
• Riwayat Intubasi endotrakeal sebelumnya
• Riwayat perawatan unit intensive sebelumnya
• Perawatan di rumah sakit non ICU 2 kali dalam 1tahun terakhir
• Kunjungan ke IGD 3 kali dalam sebulan terakhir
• Penggunaan kortikosteroid oral yang bersifat kronik
• Pengobatan yang tidak adekuat
• Penggunaan inhaler SABA 1 kanister per bulan
• Bertempat tinggal jauh dari sarana kesehatan
Apa saja yang menjadi pemicu/ trigger asma?
10
Tightened
smooth
muscles
Excess
mucus
Wall inflamed
and thickened Exercise
Pollution
Pollen
Bacteria & viruses
Narrowed airway
Animal hair
Dust
FAKTOR PENCETUS ASMA
GINA 2019: Dewasa dan Remaja 12 tahun ke atas
ICS/formoterol jika perlu
Step 5
ICS dosis
tinggi
Mengacu
pada
pengujian
fenotipe
Terapi
tambahan
seperti
tiotropium,
anti IgE, anti
IL5
+kan
steroid oral
dosis
rendah
Step 4
ICS/LABA
dosis
menengah
atau tinggi
ICS dosis
tinggi/ +kan
tiotropium/
+kan LTRA
Step 3
ICS/LABA
dosis rendah
ICS dosis
sedang atau
ICS dosis rendah
+ LTRA
Step 2
ICS dosis rendah harian
atau ICS dosis
rendah/formoterol jika perlu*
LTRA atau ICS dosis rendah Bersama dengan SABA jika perlu**
Step 1
ICS dosis rendah/formoterol
jika perlu*
ICS dosis rendah Bersama dengan SABA jika perlu**
Pilihan
Pengendali
Utama
Pilihan
Pengendali
Lainnya
14
GINA 2018
SABA jika perlu
Pilihan
Pelega Utama
Pilihan Pelega
alternatif
ICS/formoterol jika perlu#
* Off label- data hanya dengan budesonide formoterol
** Off label- Inhalasi ICS tunggal atau kombinasi dan SABA inhalasi
# ICS dosis rendah/formoterol digunakan untuk bud-form atau BDP-form Maintenance and Reliever therapy
For internal use only
Faktor Risiko Eksaserbasi PPOK
• Usia tua, jenis kelamin laki laki, kelemahan otot umum/ pernapasan, sosek ↓, mMRC ↓, depresi, gangguan tidur, bronkiektasis, konsumsi daging yang diawetkan, dan kepatuhan terhadap pengobatan.
• Risiko kambuh lebih tinggi : BMI ↓, CS sistemik dan pada kondisi obstruksi berat dan hiperinflasi.
• Derajat GOLD 2 → risiko 20% menjadi eksaserbasi
• Derajat GOLD 3 → risiko eksaserbasi dan kematian
16
Latar belakang perubahan paradigma : GOLD 2019 – penggolongan grup terapi pasien berdasarkan pada
eksaserbasi dan gejala
Adapted from the @2019 Global Initiative for Chronic Obstructive Lung Disease, all rights reserved. Use is by express license from the owner
Skala mMRC
0
1
2
3
4
Bila sesak timbul ketika terdapat aktivitas yang melibatkan sternum
Sedikit sesak ketika dalam keadaan cemas ataupun berjalan mendaki
Berjalan lebih lambat dari orang seusianya karena sesak, atau berhenti sejenak untuk bernafas ketika berjalan
Berhenti untuk bernafas setelah berjalan sejauh 100 meter atau berjalan selama beberapa menit
Terlalu sesak untuk keluar dari rumah, atau merasa sesak ketika beraktifitas ringan
Treatment of stable COPD
© 2017 Global Initiative for Chronic Obstructive Lung Disease © 2019 Global Initiative for Chronic Obstructive Lung Disease
Definition of abbreviations: eos: blood eosinophil count in cells per microliter; mMRC: modified Medical Research Council dyspnea questionnaire; CAT™: COPD Assessment Test™.
© 2017 Global Initiative for Chronic Obstructive Lung Disease © 2019 Global Initiative for Chronic Obstructive Lung Disease
Faktor Pencetus Eksaserbasi
Asma
Debu rumah, infeksi saluran napas, makanan, bumbu, obat-obatan, bulu binatang, kelelahan, bahan polusi, perubahan cuaca, emosi,
gas iritan, dan sulfur dioksida
Di Klinik Harum Melati faktor pencetus pada asma adalah asap,
penjemuran hasil panen (padi, coklat, kopi), debu, dan aktivitas
fisik berat.
PPOK
Eksaserbasi umumnya disebabkan infeksi saluran nafas.
Penyebab non infeksi adalah gagal jantung, polusi dan pencemaran
udara
Anamnesis riwayat penyakit. Tanda Vital: denyut jantung, tekanan darah, Frekuensi
nafas, Saturasi O₂ & kadar gula darah
Ringan •Berbicara dalam kalimat penuh •Penggunaan otot aksesori ringan sampai tidak ada •Mengi ringan ekspirasi saja •Tanda-tanda vital dalam batas normal •Saturasi O₂> 90% •FEV₁ atau PEF> 70% diperkirakan
Sedang •Berbicara dalam beberapa kata •Penggunaan otot aksesori ringan sampai sedang •Mengi sedang hingga berat •Saturasi O₂> 90% □ •↑ frekuensi nafas dan denyut jantung •FEV₁ atau PEF 41% -69% diprediksi
Berat •Penggunaan otot aksesori sedang sampai berat •Perubahan status mental •Saturasi O₂ <90% •↑ frekuensi nafasdan Denyut jantung •FEV₁ atau PEF <40% diprediksi
Diagnosis Banding dari Mengi
Dewasa • Infeksi saluran nafas atas • Pneumonia • Asma • PPOK • Gagal Jantung Kongestif • Bronkitis Kronik • Gastroesophageal reflux disease • Sindroma koroner akut • Embolisme paru • Benda asing • Pneumotoraks • Cytic fibrosis • Disfungsi pita suara
Anak • Infeksi saluran nafas atas •Trakeomalasia •Bronkiolitis • Asma • Pneumonia • Benda Asing
PEMERIKSAAN PENUNJANG
SPIROMETRI
Pemeriksaan laboratorium
Analisis gas darah
Elektrokardiografi
Gambaran radiologi
• Deawasa: FEV1 dan FEV1/FVC → 75% - 80% • Anak: FEV1 dan FEV1/FVC → > 85% Lakukan Uji Bronkodilator, POSITIF jika peningkatan FEV1 minimal 12%
Diagnosis PPOK ditegakkan jika nilai prediksi FEV1/FVC post bronkodilator < 70%.
ASMA
PPOK
Tidak ada tes laboratorium spesifik
Rekomendasi GOLD → pemeriksaan dahak untuk PPOK eksaserbasi akut yang gagal terapi antibiotik awal
GOLD 2019 →eosinophil > 300/ μL memerlukan terapi steroid inhalasi
Pemberian antibiotik bila CRP • < 20 mg/liter tak dianjurkan, • 20 – 40 mg/liter sputum purulen • CRP plasma darah ≥40 mg/liter
Impaired chest wall and diaphragm mechanics – work of breathing – dyspnea
Gambaran radiologi
COPD NORMAL
Elektrokardiografi
Sagging of the PR and ST segments below the TP baseline
Mutlifocal atrial tachycardia
• Multifocal atrial tachycardia • Right ventricular hypertrophy
An
alis
a G
as D
arah
• Tatalaksana eksaserbasi berat asma/ PPOK
• saturasi oksigen < 92% pada udara kamar, dan dimonitor : pH, partial pressure of CO2(PaCO2), dan PaO2
• Gagal napas : tekanan oksigen arteri (PaO2) < 60 mmHg (<8,0 kPa) dan/atau tekanan karbondioksida arteri (PaCO2) > dari 45 mmHg (>6,0 kPa).
Penatalaksanaan
Terapi SABA dan Oksigen
Inhalasi 2-agonis kerja cepat secara
terus menerus selama 1 jam
Oksigen sampai tercapai saturasi O2> 90% (95%
pada anak-anak)
Bila belum tercapai, ulangi pemberian SABA, berikan kortikosteroid oral atau sistemik jika tidak ada
respons segera
atau jika pasien
sebelumnya sudah
menggunakan steroid oral
atau jika derajat
keparahan sudah berat
Terapi oksigen
FiO₂ → tidak lebih dari 28%.
Bronkodilator harus diberikan dengan udara terkompresi daripada oksigen
O₂ tidak diberikan pada SpO₂ lebih besar dari 92%.
O₂ → 2 - 3 L melalui kanula hidung pada SpO₂ 85% s/d 92%
Masker wajah dengan aliran lebih tinggi untuk SpO₂ kurang dari 85%.
Gas darah arteri kemudian dapat diperiksa untuk memandu lebih lanjut kebutuhan oksigen.
Bronkodilator
• SABA : eksaserbasi asma ringan sedang 4-10 semprot pMDI + spacer, dosis ini diulang setiap 20 menit selama 1 jam
• SABA + SAMA :eksaserbasi PPOK akut (SABA) dan ipratropium bromide.
• LABA : diberikan sebelum pasien pulang dari rs, seperti salmeterol dan formoterol
KORTIKOSTEROID
• Pada asma anak ICS yang diberikan adalah prednisolon dengan dosis 40-50mg pada dewasa, sedangkan anak anak diberikan 1-2 mg/Kg berat badan, maksimal 40mg.
• Pada PPOK, pemberian kortikosteroid sistemik tidak lebih dari 5 – 7 hari dapat memperbaiki fungsi paru (FEV1), oksigenasi, mengurangi masa perawatan di rumah sakit
Antibiotik harus diberikan pada pasien PPOK eksaserbasi, dengan rekomendasi diantaranya
A
C
B
mempunyai tiga gejala utama → sesak nafas, peningkatan volume sputum, dan sputum purulent
peningkatan sputum yang purulent dan salah satu dari gejala utama
pasien yang memerlukan ventilasi mekanik
Lama pemakaian antibiotik yang dianjurkan adalah 5-7 hari. Biasanya antibiotik lini pertama yang digunakan adalah aminopenisilin dengan asam klavulanat, makrolida, atau tetrasiklin
Vermeerch dkk dalam penelitianny pemberian azitromisin 1x500 mg selama 3 hari saat
dirawat di rumah sakit dilanjut 1 x 250 mg setiap 2 hari selama 3 bulan pada pasien PPOK
eksaserbasi akut, menurunkan angka eksaserbasi akut dan mortalitasnya
Magnesium sulfat intravena
• Mengurangi kebutuhan untuk masuk rumah sakit untuk orang dewasa dibandingkan dengan plasebo, MgSO4 dosis 40mg/Kg BB IV dapat mengurangi kebutuhan untuk masuk RS pada anak-anak yang datang ke UGD dengan asma eksaserbasi sedang hingga berat.
Non invasive ventilation dan invasive Mechanical ventilation
Ventilasi noninvasif dapat dipertimbangkan pada pasien PPOK eksaserbasi akut dengan asidosis respiratorik (pH <7,35; PaCO2 >6,0 kPa) yang tidak membaik dengan terapi medis standar dan telah mendapat terapi oksigen selama satu jam
Pada mekanik ventilasi invasif indikasinya adalah sebagai berikut : asidosis yang berat (pH 7,25), dan atau hiperkapnia (PaCO2 > 8.0 kPa)
Farmakologi Non
Farmakologi Pencegahan Eksaserbasi
• Hindari pencetus Edukasi, self management, nutrisi,aktivitas fisik dan rehabilitasi medik. • PPOK → Lung Volume Reduction, terapi oksigen dan ventilasi mekanik di rumah.
• Asma → inhaler kortikosteroid dosis rendah dengan formoterol setiap hari. • Asma yang parah → kortikosteroid inhalasi dosis tinggi (ICS) ditambah obat pengontrol lini kedua. • PPOK harus mendapatkan bronkodilator (LABA, LAMA, LAMA + LABA) atau kombinasi bronkodilator dan kortikosteroid (LAMA + ICS, LAMA + LABA + ICS) untuk PPOK yang berisiko mengalami eksaserbasi. •Pencegahan infeksi melalui vaksin, dan profilaksis berupa makrolida jangka panjang
Edukasi Pasien Saat Pulang
1 • Mengenal pemicu eksaserbasi
2
• Menerangkan waktu pemberian, dosis, efek samping, dan interaksi dengan obat lain, memperagakan pemakaian inhaler
3
• Aktivas apa yang harus dihindari serta apa yang bisa dilakukan.
4
• Mengenal gejala eksaserbasi → batuk baik kering maupun berdahak, sesak , demam atau gejala sistemik yang lain.
5 • Mengetahui siapa yang harus dihubungi dan kapan harus
ke rumah sakit, serta kapan harus dievaluasi.
BACK
TERIMA KASIH
Written asthma action plans
GINA 2017, Box 4-2 (1/2)
Effective asthma self-management education requires:
• Self-monitoring of symptoms and/or lung function
• Written asthma action plan
• Regular medical review
If PEF or FEV1
<60% best, or not
improving after
48 hours
Continue reliever
Continue controller
Add prednisolone 40–50 mg/day
Contact doctor
All patients
Increase reliever
Early increase in controller as below
Review response
EARLY OR MILD LATE OR SEVERE
• Increase inhaled reliever – Increase frequency as needed – Adding spacer for pMDI may be helpful
• Early and rapid increase in inhaled controller – Up to maximum ICS of 2000mcg BDP/day or equivalent – Options depend on usual controller medication and type of LABA – See GINA 2017 report Box 4-2 for details
• Add oral corticosteroids if needed – Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days – Children: 1-2mg/kg/day up to 40mg, usually 3-5 days – Morning dosing preferred to reduce side-effects – Tapering not needed if taken for less than 2 weeks – Remember to advise patients about common side-effects (sleep
disturbance, increased appetite, reflux, mood changes)
Written asthma action plans – medication options
GINA 2017, Box 4-2 (2/2)
UPDATED
2017
Managing exacerbations in primary care
GINA 2017, Box 4-3 (1/7)
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
ASSESS the PATIENT
Is it asthma?
Risk factors for asthma-related death?
Severity of exacerbation?
MILD or MODERATE
Talks in phrases, prefers
sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
LIFE-THREATENING
Drowsy, confused
or silent chest
START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg
Controlled oxygen (if available): target
saturation 93–95% (children: 94-98%)
CONTINUE TREATMENT with SABA as needed
ASSESS RESPONSE AT 1 HOUR (or earlier)
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled
SABA and ipratropium bromide,
O2, systemic corticosteroid
URGENT
WORSENING
ARRANGE at DISCHARGE
Reliever: continue as needed
Controller: start, or step up. Check inhaler technique, adherence
Prednisolone: continue, usually for 5–7 days (3-5 days for children)
Follow up: within 2–7 days
ASSESS FOR DISCHARGE
Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal best or predicted
Oxygen saturation >94% room air
Resources at home adequate
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
IMPROVING
WORSENING
SEVERE
Talks in words, sits hunched
forwards, agitated
Respiratory rate >30/min
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF ≤50% predicted or best
© Global Initiative for Asthma © Global Initiative for Asthma GINA 2017, Box 4-3 (2/7)
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
ASSESS the PATIENT
Is it asthma?
Risk factors for asthma-related death?
Severity of exacerbation?
LIFE-THREATENING
Drowsy, confused
or silent chest
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
URGENT
© Global Initiative for Asthma © Global Initiative for Asthma GINA 2017, Box 4-3 (3/7)
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
ASSESS the PATIENT
Is it asthma?
Risk factors for asthma-related death?
Severity of exacerbation?
MILD or MODERATE
Talks in phrases, prefers
sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
SEVERE
Talks in words, sits hunched
forwards, agitated
Respiratory rate >30/min
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF ≤50% predicted or best
LIFE-THREATENING
Drowsy, confused
or silent chest
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
URGENT
© Global Initiative for Asthma © Global Initiative for Asthma GINA 2017, Box 4-3 (4/7)
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
ASSESS the PATIENT
Is it asthma?
Risk factors for asthma-related death?
Severity of exacerbation?
MILD or MODERATE
Talks in phrases, prefers
sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
SEVERE
Talks in words, sits hunched
forwards, agitated
Respiratory rate >30/min
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF ≤50% predicted or best
LIFE-THREATENING
Drowsy, confused
or silent chest
START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg
Controlled oxygen (if available): target
saturation 93–95% (children: 94-98%)
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
URGENT
WORSENING
© Global Initiative for Asthma GINA 2017, Box 4-3 (5/7)
START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg
Controlled oxygen (if available): target
saturation 93–95% (children: 94-98%)
CONTINUE TREATMENT with SABA as needed
ASSESS RESPONSE AT 1 HOUR (or earlier)
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
WORSENING
ASSESS FOR DISCHARGE
Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at home adequate
IMPROVING
WORSENING
© Global Initiative for Asthma GINA 2017, Box 4-3 (6/7)
START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg
Controlled oxygen (if available): target
saturation 93–95% (children: 94-98%)
CONTINUE TREATMENT with SABA as needed
ASSESS RESPONSE AT 1 HOUR (or earlier)
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
WORSENING
ARRANGE at DISCHARGE
Reliever: continue as needed
Controller: start, or step up. Check inhaler technique,
adherence
Prednisolone: continue, usually for 5–7 days
(3-5 days for children)
Follow up: within 2–7 days
ASSESS FOR DISCHARGE
Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at home adequate
IMPROVING
WORSENING
© Global Initiative for Asthma GINA 2017, Box 4-3 (7/7)
START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg
Controlled oxygen (if available): target
saturation 93–95% (children: 94-98%)
CONTINUE TREATMENT with SABA as needed
ASSESS RESPONSE AT 1 HOUR (or earlier)
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid
WORSENING
ARRANGE at DISCHARGE
Reliever: continue as needed
Controller: start, or step up. Check inhaler technique,
adherence
Prednisolone: continue, usually for 5–7 days
(3-5 days for children)
Follow up: within 2–7 days
ASSESS FOR DISCHARGE
Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at home adequate
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
IMPROVING
WORSENING
Managing exacerbations in acute care settings
GINA 2017, Box 4-4 (1/4)
Are any of the following present?
Drowsiness, Confusion, Silent chest
Further TRIAGE BY CLINICAL STATUS
according to worst feature
MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
SEVERE
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
PEF ≤50% predicted or best
Short-acting beta2-agonists
Consider ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral corticosteroids
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat as
severe and re-aassess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY
MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF 60-80% of predicted or
personal best and symptoms improved
MODERATE
Consider for discharge planning
FEV1 or PEF <60% of predicted or
personal best,or lack of clinical response
SEVERE
Continue treatment as above
and reassess frequently
NO
YES
Consult ICU, start SABA and O2,
and prepare patient for intubation
INITIAL ASSESSMENT
A: airway B: breathing C: circulation
© Global Initiative for Asthma GINA 2017, Box 4-4 (2/4)
INITIAL ASSESSMENT
A: airway B: breathing C: circulation
Are any of the following present?
Drowsiness, Confusion, Silent chest
Further TRIAGE BY CLINICAL STATUS
according to worst feature
Consult ICU, start SABA and O2,
and prepare patient for intubation
MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
SEVERE
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
PEF ≤50% predicted or best
NO
YES
GINA 2017, Box 4-4 (3/4)
MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best
SEVERE
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
PEF ≤50% predicted or best
Short-acting beta2-agonists
Consider ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral corticosteroids
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
© Global Initiative for Asthma GINA 2017, Box 4-4 (4/4)
Short-acting beta2-agonists
Consider ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral corticosteroids
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 93–95% (children 94-98%)
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat as
severe and re-assess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY
MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF 60-80% of predicted or
personal best and symptoms improved
MODERATE
Consider for discharge planning
FEV1 or PEF <60% of predicted or
personal best,or lack of clinical response
SEVERE
Continue treatment as above
and reassess frequently
• Follow up all patients regularly after an exacerbation, until symptoms and lung function return to normal – Patients are at increased risk during recovery from an exacerbation
• The opportunity – Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patient’s asthma management
• At follow-up visit(s), check: – The patient’s understanding of the cause of the flare-up – Modifiable risk factors, e.g. smoking – Adherence with medications, and understanding of their purpose – Inhaler technique skills – Written asthma action plan
Follow-up after an exacerbation
GINA 2017, Box 4-5
Elektrokardiografi
Adanya gelombang S dalam sadapan I, II, dan III, R / S rasio kurang dari 1 pada sadapan V5 atau V6; dan, tanda sadapan I yang berupa gelombang P isoelektrik, amplitudo QRS kurang dari 1,5 mm, dan amplitudo gelombang T kurang dari 0,5 mm pada pada sadapan I.
Sederhana → menemukan gelombang P dalam sadapan aVL, atau amplitudo gelombang P pada sadapan III lebih besar
daripada pada sadapan I.